Friday, October 31, 2008

On Election Day, Arizonans can give the nation the gift of a good example. They can enact a measure that could shape the health-care debate that will arrest or accelerate the nation's slide into statism. Proposition 101, the Freedom of Choice in Health Care Act, would put the following language into Arizona's Constitution:

"Because all people should have the right to make decisions about their health care, no law shall be passed that restricts a person's freedom of choice of private health care systems or private plans of any type. No law shall interfere with a person's or entity's right to pay directly for lawful medical services, nor shall any law impose a penalty or fine, of any type, for choosing to obtain or decline health care coverage or for participation in any particular health care system or plan."

Will discusses his reasons for supporting the ballot measure. I only wish there were a similar measure to support here in Colorado.

I highly recommend reading the whole thing, especially if you want a perspective from someone who has been in the trenches.

I've selected a few excerpts to highlight.

On inequality:

...I've seen more inequity and disparity in Canada than the United States, as far as access to care. As I mentioned, we had huge waiting lists. Our MRI waiting list was 13 months long. Our CT scan waiting list was seven months long. People in that system really were just left to suffer to a much greater degree than they are here in the United States.

One thing that you see that is not talked about very much is that Canadians with influence or connections tend to get medical attention more quickly. I would get telephone calls from various doctors requesting that their patients be moved up on the waiting list. If they made a reasonable case, I would do so, whereas there were other doctors who just referred people for imaging tests, and I never heard specific requests from those doctors. Their patients would just go to the end of the waiting list because they didn't have the same level of advocacy. The other thing -- and it's kind of a deep, dark secret -- is if you are connected to somebody in the medical system, you're much more likely to get your medical intervention done more quickly, whether by knowing a doctor, knowing somebody in the hospital administration, or whatever.

On the "dying in the streets" argument:

...In Canada there's a false perception, which I actually held for many years, that if you don't have health insurance in the United States, you literally do not get care. There's a perception in Canada that in the United States if you don't have insurance and you have a problem, you’re going to get turned away and that people are just dying in the streets for lack of health care. I've been in America for almost six years, and I've yet to see anybody who’s been turned away for health care -- at least in Minnesota. Whereas, the reality is that Canadians are turned away for health care in many different ways -- through waiting lists for access.

On central planning vs. the free market:

When I was working in Canada, we had this personnel meltdown when we had only three radiologists for 250,000 people. I was director of the department at the time, and I said to the hospital administration, "We need a rolloscope." A rolloscope is a device where the X-rays and CT scans are set up on the scope, and you can push a button and go from case to case to case. It really expedites your ability to read the cases promptly. I was reading about 40,000 cases a year at that time, which is just an enormous number, especially if you're reading without a rolloscope. The hospital said, "Well, you know, what? There's no money in the budget for us to buy your rolloscope. Perhaps, you could plead the case to the Ministry of Health. Perhaps, they can make a special dispensation of dollars so that you can get this rolloscope." The radiologists in Thunder Bay eventually got the rolloscope three years later, but there was no money to hire a clerk to load the films, so it just sat and collected dust for another year.

When I moved to Minnesota, I worked at St. Francis Medical Center in Shakopee, and we were seeing increasing volumes and just getting busier, and busier, and busier. My partner and I approached our organization, Consulting Radiologists Limited, and said, "We need a rolloscope. We've got these increasing volumes." They looked and said, "Hey, you guys are phenomenally productive. We want to facilitate your productivity. Here's your rolloscope." We had the rolloscope in a month, and we had someone to load it, too. That's the free market versus central planning.

On health insurance:

Certainly, I'm not against health insurance. I would never go without it, but, on the other hand, a lot of policies are not just insurance. They're prepaid medical plans. When everything is covered, then there's no restraint. I want insurance for the catastrophic illness that I may get or if I get in a bad car accident and I have really high costs. I don't really want to have to pay insurance for routine things like my daughter's sore throat or immunization or something like that, which is routine and expected.

A good analogy would be house insurance. House insurance is pretty reasonably priced, and it is because we have it for unexpected problems, like our house burning down or being robbed. My premiums reflect the fact that these are unlikely eventualities. On the other hand, if house insurance was based on all of my needs for my household -- floor wax, paint, dishwashing soap, new clothes, or whatever -- then, as a consumer, I would say, "The sky is the limit. Let's paint the walls every week. Let's put in new carpets every week." The cost for home insurance would be astronomical, and yet that is the exact situation that we have with the standard health insurance in the United States right now.

Wednesday, October 29, 2008

KevinMD.com has a good round-up of the current status of the post-op complications associated with the knee surgery on Tom Brady, quarterback for the New England Patriots football team.

But the most interesting bit was the following comment from another physician:

Imagine, the whole world is watching. The greatest football players going to the greatest surgeons at the greatest hospitals. An athelete at the top of his physical health.

And they can't prevent billions of years of bacterial evolution from infecting the man's knee.

Yet the clowns at the Medicare National Bank want to make perioperative infections, specifically for orthopaedic surgeries, a "never event".

You have just witnessed the ridiculous policies of a government agency gone mad. When you have the best surgeons treating the most physically fit patients at the best hospitals, with the whole world watching, and you STILL get an infection, you have no credibility as an organization when you suggest the rest of us humble simpleton providers could be perfect in our outcomes. A "never event" is just that. Never. And that is simply not possible.

If physicians are to be held to a standard of perfection, what about the politicians?

Tuesday, October 28, 2008

Sen. Barack Obama's claim that health care is a "right" typifies a dangerous political trend.

A right is a freedom of action (such as the right to free speech), not an automatic claim to a good or service that must be produced by another. Attempting to guarantee a supposed "right" to health care must necessarily violate actual rights of providers or of citizens forced to pay for others' medical expenses. This is just state-sanctioned slavery or theft.

Instead of another massive government program to guarantee "universal health care," we need free-market reforms that would allow individuals to purchase health insurance across state lines, use Health Savings Accounts for routine expenses, and purchase inexpensive catastrophic-only policies for rare but expensive problems. Such reforms could cut costs by as much as 50 percent, making quality health insurance affordable to many who want to purchase it but currently can't.

Monday, October 27, 2008

The October 19, 2008 Boston Globe has a piece by Jeff Jacoby explaining how the US ended up with the bizarre system of health insurance as part of one's job benefits. At root, the problem was government interference with the free market:

Healthcare shouldn't be linked to employment

...[W]hat's unnatural is the link between healthcare and employment. After all, we don't rely on employers for auto, homeowners, or life insurance. Those policies we buy in an open market, where numerous insurers and agents compete for our business. Health insurance is different only because of an idiosyncrasy in the tax code dating back 60 years - a good example, to quote Milton Friedman, of how one bad government policy leads to another.

During World War II, federal wage controls barred employers from raising their workers' salaries, but said nothing about fringe benefits. So firms competing for employees at government-restricted wages began offering medical insurance to sweeten employment offers. Even sweeter was that employers could deduct those benefits as business expenses, yet employees didn't have to report them as taxable income. For a while the IRS resisted that interpretation, but Congress eventually enshrined the tax-exempt status of employer-based medical insurance in law.

Result: a radical shift in the way Americans paid for medical care. With health benefits tax-free if they were employer-supplied, tens of millions of Americans were soon signing up for medical insurance through work. As tax rates rose, so did the incentive to keep expanding health benefits. No longer was medical insurance reserved for major expenditures like surgery or hospitalization. Americans who would never think of using auto insurance to cover tune-ups and oil changes grew accustomed to having their medical insurer pay for yearly physicals, prescriptions, and other routine expenses.

As Jacoby concludes, "De-linking medical insurance from employment is the key to reforming healthcare in the United States." I agree -- this is one of the most critical free market reforms to implement.

Health care has been an important issue in politics, especially in the last several years. Amidst much specific policy analysis and political quibbling over superficial issues, the fundamentals have been ignored: What are the underlying philosophic and economic considerations? Is universal health care moral? Does it achieve its stated goal? Is there an ethical and practical alternative?

Saturday, October 25, 2008

The October 23, 2008 edition of The Economist has printed another LTE of mine, this time on Massachusetts' health care "reform". This one is in the print edition (as opposed to my first LTE there which was online-only.)

They did minor editing, but kept the central meaning intact. The letter is the 4th one down:

Freedom to choose

SIR – The Massachusetts system of "universal" health care remains afloat only because of hundreds of millions of dollars in federal support ("In need of desperate remedies", October 18th).

One reason costs are so high in Massachusetts is that individuals are forced to purchase benefits they neither need nor want. Under any system of mandatory insurance, the state must necessarily define what constitutes an acceptable insurance policy, meaning that individuals are buying insurance on terms influenced by lobbyists and bureaucrats, rather than based on a rational assessment of their needs.

If the federal government adopts the Massachusetts system on a national scale, it would merely multiply those problems fifty-fold.

Friday, October 24, 2008

Well it's been two weeks since "never events" were implemented. What changes have been made?

Probably the biggest change in our ED is the decrease in use of Foley catheters. Since October 1, a Foley cannot be placed without an order that also states the medical necessity for the catheter. The doctors apparently don't want to have their judgment questioned, so very few patients get Foley catheters any more.

...I'm sure that the decrease in Foley catheter use will also decrease the number of UTIs due to Foley catheter use. That's a good thing, right?

...How do you tell if an infection is "from using tubes"? I was able to find one lecture from a UK physician that defined a catheter associated UTI as one in which "An indwelling catheter is in situ at time of onset of UTI" -OR- "An indwelling catheter was removed within 3 days prior to the onset of UTI." Both definitions require an indwelling catheter. Therefore if no indwelling catheters are used and only a straight catheter being used repeatedly, by this definition a "catheter associated UTI" cannot develop.

That explains one of the other things I am seeing: Instead of getting indwelling Foley catheters, patients are now repeatedly getting straight catheters to retrieve urine. That amounts to more work for the nurses, more patient discomfort, and more trauma to the urethra as the catheter is repeatedly inserted.

...Will the decrease in UTIs offset the inevitable increase in the numbers of decubitus ulcers, the decrease in patient comfort, and the lack of trust in the medical system when "that nurse just left grandma laying in her urine all afternoon"? That remains to be seen, but I doubt it.

I'm predicting that this won't be the only unintended consequence of these new government laws...

Thursday, October 23, 2008

The positives far outweigh the negatives for the responsible consumer. And as more patients adopt these sorts of plans (thus achieving a critical market share), I anticipate that the hassles HSA clients experience with insurance companies and providers' offices will start to decline.

Wednesday, October 22, 2008

Brian Lee Crowley, a senior fellow at the Galen Institute, gave the following speech about physician disempowerment in Canada at the recent Center for Medicine in the Public Interest conference on October 14, 2008.

1) Potential physicians are severely restricted in their ability to choose their profession2) Physicians are increasingly restricted in whom they can see3) Physicians are increasingly restricted in what they can prescribe4) Physicians are increasingly restricted in getting their patients access to the latest technology5) Physicians have totally lost the power to determine what they will charge6) Physicians are gaining some slight ability to practice in both the public and the private sectors after having lost that right for years.7) Physicians have great difficulty getting their patients treated in a timely manner

Point 6 is the one slender silver lining in the otherwise bad news.

The others are the inevitable consequences of any system of "universal health care".

When the government attempts to guarantee a good or service such as health care as a universal "right", it must necessarily control the creation and distribution of that service. This removes the control from the physicians who create the service and the patients who purchase it. Instead, the government determine who gets what care and when. In the end, rather than being a "right", health care becomes a de facto privilege dispensed at the discretion of bureaucrats.

Tuesday, October 21, 2008

The October 14, 2008 edition of The Economist magazine has posted my LTE on health care, written in response to their article on health care in the US presidential race, "Running For Cover" from two weeks ago.

(It did not appear in the printed edition, only in the online edition):

Running for cover, October 4th

SIR - Governments should not guarantee health care as a "right" ("Running for cover", special briefing on the US election, October 4th). Rights are freedoms of actions (such as the right to free speech), not automatic claims on goods and services that must be produced by others.

Individuals are legitimately entitled to services such as health care that they purchase with their own money, are promised by prior contractual agreements, or are given to them via voluntary charity.

Otherwise, government programs to guarantee health care as a "right" must necessarily violate someone's actual rights - either the rights of those compelled to provide medical care or the rights of those compelled to pay for it. Such programs then become just another form of state-sanctioned slavery or theft.

Dozens of incentive schemes have been uncovered which allow GPs to profit by slashing the number of patients they refer for hospital care.

Under one scheme, GPs stand to gain £59 for every patient not referred to hospital, if they cut an average referral rate by between two and eight per cent.

...A leading surgeon said that patients' cancers had already gone undiagnosed after they were denied specialist care under two such "referral management" schemes.

Orthopaedic surgeon Stephen Cannon... said: "I recently encountered two cases in which patients referred to physiotherapists later turned out to have a malignant tumour. If they had been sent to a consultant the outcome may have been very different.

"In one case a young man was referred to a physiotherapist because of sudden knee pain. Had he come to a specialist the symptoms should have been recognised and he should have been urgently referred to an oncologist. In this case, after the delays, the outcome was amputation. It was devastating for the patient and his family.

Remember, this is the "compassionate" system of socialized medicine, in which all patients have a theoretical "right" to health care.

Of course, in reality, whenever a government attempts to guarantee health care as a right, it must also control that service. Far from being a "right", health care becomes a privilege dispensed at the discretion of government bureaucrats.

Cost containment will eventually take precedence over quality of care. The results in UK are tragic, but should not be surprising. The only question is whether Americans will learn from this example...

Thank you for your healthy skepticism about Obama's proposed health care "reforms". The last thing this country needs is a massive new bureaucracy that would crowd out private health insurance. The Obama plan would be just another step towards a complete government takeover of American medicine.

We've already seen this with Medicare, which has essentially destroyed primary private health insurance for American over age 65. Older Americans essentially live under a system of socialized medicine, and every year we see how their health care is held hostage to partisan political wrangling.

Do we really want to inflict this on all Americans?

There are genuine problems with the current health care system.

But forcing everyone into a government-run health system to "solve" the problem of the uninsured would be like forcing everyone into government-run housing projects to "solve" the "problem of homelessness".

Saturday, October 18, 2008

Gov. Linda Lingle's administration cited budget shortfalls and other available health care options for eliminating funding for the program. A state official said families were dropping private coverage so their children would be eligible for the subsidized plan.

"People who were already able to afford health care began to stop paying for it so they could get it for free," said Dr. Kenny Fink, the administrator for Med-QUEST at the Department of Human Services. "I don't believe that was the intent of the program"...

We've seen similar problems in other states such as Tennessee, where a government "right" to health care undermines and eventually destroys the private market. This in turn leaves patients and physicians at the mercy of government bureaucrats.

Fortunately, Hawaii learned this lesson before it was too late. Will the rest of America?

Friday, October 17, 2008

...Constitutional rights protect us from things: intimidation, illegal search and seizure, self-incrimination, and so on. The revolutionary idea of our Founding Fathers was that people had a God-given right to live as they saw fit. Our constitutional rights protect us from the power of government.

But these new so-called "rights" are about the government -- who the Founders saw as the enemy -- giving us things: food, health care, education... And when we have a right to be given stuff that previously we had to work for, then there is no reason -- none -- to go and work for them. The goody bag has no bottom, except bankruptcy and ruin.

Does that ring a little familiar these days? Because isn’t the danger here that if you’re offered something for nothing... you'll take it?

Only it's not something for nothing. "Free" health-care costs us something precious, and no less precious for being invisible. Because there's a word for someone who has their food, housing and care provided for them... for people who owe their existence to someone else.

And that word is "slaves."

Whittle identifies the central issue -- rights are freedoms of action (and corresponding restrictions of government power). They are not entitlements to goods and services that must be produced by others.

I also liked his identification of the fact that a welfare state turns both the producers and the recipients of these redistributed goods into slaves. That's a point that cannot be emphasized enough.

(Disclaimer: This should not be construed as any kind of general endorsement of NRO or Whittle. I like much of Whittle's writings, although I have disagree with his characterization of rights as "God-given". For a secular discussion of the nature of rights and the objective facts that give rise to that concept, see "Man's Rights" by Ayn Rand. I also have other disagreements with Whittle on issues not related to this particular topic.)

Thursday, October 16, 2008

The October 14, 2008 edition of the New Jersey Star-Ledger printed the following LTE by Mike LaFerrara supporting free market health care reforms in New Jersey:

Insurance freedom

A free market is a recognition of every individual's inalienable right to think and act on his own judgment, including entering freely into contractual agreements with others for his own well-being. It leaves him free from coercive interference by others, including government officials and politicians. Anything else is a violation of those rights. The health insurance crisis is directly attributable to the lack of a free market.

Assembly Bill 2767, the New Jersey Healthcare Choice Act, would be a huge step toward rectifying this injustice. The bill would open up New Jersey's insurance market to policies offered in any state. Individuals and health insurance companies from around the country would be free to contract voluntarily to mutual advantage. Unfortunately, a hearing on this bill is being blocked in committee, according to one of its sponsors, Assemblyman Jay Webber.

Insurance Committee Chairman Gary Schaer should end this blockage. If "government of the people" means anything, Trenton should end the rights-violating restraint-of-trade practice of forbidding state residents from buying out-of-state health insurance policies and enact this bill into law.

-- Michael A. LaFerrara, Flemington

This would be a good step in the right direction. Plus, state legislatures could easily implement this reform without permission from the federal government -- all they need is the political will.

Wednesday, October 15, 2008

The Obama plan, meanwhile, gives birth to a bouncing new bureaucracy: the National Health Insurance Exchange...

Over time, for that matter, some federal entity would have to decide what would be added and subtracted by the public plan -- in order to control costs, among other reasons. Former Sen. Tom Daschle, a longtime universal health care proponent and Obama adviser, has touted his idea for a Federal Health Board to make those sensitive choices. That also makes us nervous.

The October 3, 2008 Washington Post also does a little fact-checking on Biden's claims about the McCain plan during the recent Vice-Presidential Debate. They conclude that his criticisms are misleading:

Joe Biden gave the impression that most Americans would be worse off financially as a result of Sen. John McCain's health-care proposals. He drew on a study by the journal Health Affairs to suggest that 20 million people would lose their company-provided health insurance under the McCain plan. He failed to note that the same journal calculated that another 21 million people would be able to afford health insurance for the first time because of tax credits offered under the McCain plan.

...According to the nonpartisan Tax Policy Center, the McCain proposals would result in a net benefit of $1,241 to the average taxpayer in 2009, $895 in 2013, and $386 in 2018. Taxpayers in the top quintile would be slightly worse off by 2018, but other taxpayers would be slightly ahead.

Tuesday, October 14, 2008

The October 13, 2008 Rocky Mountain News carried the following LTE by Tish Jeffers on Canadian health care:

Socialized medicine great, but don't get sickTish Jeffers, Centennial

I had the opportunity to live in Canada for almost 20 years, so I think I have a fair background in how socialized, government-orchestrated medicine works.

Keep in mind, there are approximately 32 million people in Canada and approximately 302 million people in the United States.

My assessment then, as it is now when I talk to my aging Canadian friends: Socialized medicine is great... as long as you never get really sick!

What I find interesting is that if socialized medicine ever comes into play here in the United States, Americans will never stand for the waiting, the lines, the paperwork and the bureaucracy the Canadians put up with when they go to the doctor. We won't have the option, like our Canadian friends do, to load up on buses and come over to the United States to get the instant care most of us take for granted!

It isn't medicine that needs reform, it's the insurance companies that need reform. The government has screwed up so many things, like our current issue with our finances! Do we want them messing around with our medicine, too?

Jeffers is quite right -- the Canadian system controls costs through rationing and waiting lists.

However, the problems in the US should not be blamed solely on insurance companies. Much of their behaviour is driven by onerous government regulations that prevent them from offering cost-effective services in a free market to willing customers. For more, please see our article on "universal health care".

Monday, October 13, 2008

Blogger Michael Williams discusses why health care is not a right. He correctly notes that rights impose only negative obligations on people, not positive entitlements. Here are a few excerpts from his essay:

...[T]hink about what it would mean for health care to be a right. When you consider the ramifications even an inch beneath the surface you run into all sorts of problems.

Every right one person has imposes an obligation on someone else:

* Right: Free speech. Obligation: We have to let you talk, even when you stay stupid or dangerous things.* Right: Free religion. Obligation: We have to let you go to any church you want, or none at all, even if we think you're corrupting our country.* Right: Free assembly. Obligation: We have to let you meet with your dumb friends.* Right: Due process. Obligation: We have to give you a trial, even when it's clear that you're guilty.

...With the exception of the right to trial-by-jury, I think all the rights specified in the Constitution create negative obligations on the rest of society. Your right obligates me and the government to not do anything to impede it. In contrast, positive obligations require me not just to leave you alone, but to actually do something for your benefit.

He notes that any alleged "right" to health care actually means the following:

* Taxpayers will be obligated to pay for others' health care under threat of force* Doctors will be obligated to provide health care at the government's direction* Insurance companies will be obligated to cover or not cover people or ailments at the government's direction* Employers will be obligated to pay for health care of whatever kind mandated by the government

The issue of health care really cuts to the core of the difference between leftists and conservatives.

Conservatives believe that "rights" express our fundamental freedoms that cannot be taken away by anyone. The only obligations created by conservative "rights" are negative obligations that require you to stay out of my business.

Leftists believe that "rights" express obligations that the government can impose on us by force. Leftist "rights" create obligations on us to spend our time, money, and effort on other people regardless of our own desires. That's not freedom, that's slavery.

He is absolutely correct in his assessment that entitlement rights are just a form of state-sanctioned slavery. And I completely agree with his major points.

For a discussion and defense of the nature of individual rights on fundamental philosophical grounds, I highly recommend the classic essay by Ayn Rand, "Man's Rights".

I do have two additional remarks.

First, the biggest problems with modern conservatives is that too many are deliberately straying from the classical liberal ideals of an earlier generation marked by a respect for individual rights. When self-described "conservatives" advocate for more government interference with individual rights, such as Mitt Romney's mandatory insurance requirement in Massachusetts or McCain's calls for greater environmental regulations, the political debate then becomes between different forms of statism, not between freedom and slavery. This is painfully obvious in the current 2008 election cycle. Professor Bradley Thompson has written a detailed analysis of the problems with modern conservatism in this The Objective Standard article, "The Decline and Fall of American Conservatism".

Second, I think one can make an argument that jury duty can and should be voluntary. But this is a very minor and peripheral issue, better suited for a different venue.

Friday, October 10, 2008

Medicare (aka CMS or Centers for Medicare/Medicaid Services) has now implemented a policy of not paying for certain bad patient outcomes that they call "never events". These include certain kinds of bedsores, post-operative infections, etc.

It's being portrayed as a measure to ensure quality and reduce costs. But physician-blogger WhiteCoatRants predict it will lead to some nasty unintended consequences:

1. You'll get diagnosed with a lot more illnesses so that it is very difficult to determine what care is not for a "never event" and what care is for the "never event." Then when you have to stay in a hospital longer because of a "never event," the hospital can allege that the extended stay was really due to a problem that was not a never event. That will mean more testing, more procedures, and higher costs.

2. If you develop a "never event," you’ll be more likely to get transferred to another hospital. CMS won't pay for never events if they develop in a hospital, but they will pay for treatment if you present with a pre-existing never event. Hospitals will develop unwritten agreements that certain specialists at each other's facilities are better suited to treat a certain patient's "never event." More transfers mean more redundant testing, higher costs, and more complications from the testing.

3. Testing and diagnosis of never-event conditions will diminish where feasible. That bedsore isn't a Grade 3 - it's only Grade 2. CMS will pay for those.

He predicts that these measures won't actually control costs. Then the government will propose to "rescue" the failing system with a complete takeover:

Enter the knight in the shining armor -- the same government that put us into this mess. "Let's try universal healthcare/single payor," the knight says from atop his noble steed.

...Whichever way you look at it, healthcare as we know it is about to change for the worse.

We're screwed.

Although I hope he's wrong, I fear he's right. Hence, one important point that physicians and policy makers should keep in mind as this process unfolds over the next few years is to make sure that the blame for these unintended consequences is placed where it belongs -- on new government rules and regulations. If legislators recognize that skyrocketing costs are caused by the government, then they might do the right thing and repeal some bad laws. But if they are only told that the problem is "greedy" insurance companies or "greedy" physicians, then this will give them more reasons to press for full-bore socialized medicine.

Unfortunately, both candidates are trying to deny the obvious. Health care is a commodity in the broadest sense of that term: a good or service created by businessmen for trade in the marketplace. As such, the producers of health care (like the producers of any other commodity such as food, shelter, or cell phones) require freedom in order to produce. Government regulations that infringe upon that freedom will stop producers from creating this valuable commodity, as we've already seen in countries such as Canada and the UK.

The fact that modern health care is essential for human life makes it all the more crucial to allow the free market to work and to restrain the government from violating the rights of patients and health care providers. Any attempts by the government to guarantee health care as a "right" necessarily violates someone's actual rights -- either the providers or those forced to pay for others' health care against their will or both. Hence, Americans must reject the flawed notion of health care as some sort of "right" and embrace the fact that it is a commodity.

For the proper approach to thinking about this issue, I know of no better starting point than Dr. Leonard Peikoff's, "Health Care Is Not A Right".

...[L]et's deregulate medical care so that providers can find innovative ways to deliver high-quality care cheaply. Let's eliminate the increasingly strict education requirements for clinicians and let medical professionals offer walk-in physicals or other services at competitive prices. Like Wal-Mart and MinuteClinic, they will rely on brand name and reputation to assure quality.

We also need to better promote health savings accounts, which put spending in the hands of consumers and encourage them to shop around for low-cost alternatives.

Retail clinics are only the first step. My hope is that the increased access and reduced costs will quickly become evident and will build support for additional innovations -- and the deregulatory policies necessary to make them possible.

Universal coverage sounds appealing, but it means government will be running the trains. Here and abroad, government does not have a good record when it comes to access, oversight or innovation.

Her economic arguments are sound, and they provide good reinforcement of the more fundamental rights-based ethical argument for free market health care reforms. (Via Kelly McNulty.)

The study shows that health care in Canada appears to cost less because relative to the United States, Canadian public health insurance does not cover many advanced medical treatments and technologies, common medical resources are in short supply, and access to health care is often severely delayed.

"On average, Americans spend more of their incomes on health care but they get better access to superior medical resources," [co-author Brett] Skinner said.

"If Canadians had access to the same quality and quantity of health-care resources that American patients enjoy, the Canadian health-insurance monopoly would cost a lot more than it currently does."

According to the most recent data, the United States outscores Canada on many key indicators of available health care resources, including:

* Number of MRI units per million population in 2006: US: 26.5; Canada: 6.2* Number of MRI exams per million population in 2004/05: US: 83,200; Canada: 25,500* Number of CT Scanners per million population in 2006: US: 33.9; Canada 12* Number of CT exams per million population in 2004/05: US: 172,500; Canada 87,300* Number of inpatient surgical procedures per million population in 2004: US: 89,900; Canada: 44,700.

...Even on health insurance coverage, the Canadian system does not perform much better than the U.S. when it comes to actually delivering insured access.

"Access to a wait list is not the same thing as access to health care," Skinner said.

The study cites government data showing an estimated 1.7 million Canadians (aged 12 and older) were unable to access a regular family physician in 2007. And it points to other research showing that the actual number of "effectively" uninsured Americans is less than half of the figure usually reported and that being uninsured is usually only a temporary condition.

Based on these figures, the study estimates that the percentage of the population that was "effectively" uninsured for non-emergency, necessary medical services at any given time during 2007 was not significantly different between the two countries: 7.9 percent in the U.S. compared to six percent in Canada.

"When Canadians can't get access to health care because they can't find a physician or wait so long that they are effectively uninsured, they are no better off than uninsured Americans," Skinner said.

(For the record, I do disagree with the authors' support of an individual insurance mandate for reasons covered here.)

Monday, October 6, 2008

First, she has a nice writeup of Dr. Steven Knope's efforts to practice quality medicine free from onerous insurance company restrictions in a concierge practice. For more on this, see his blog.

Second, she reports on the proposed "Freedom of Choice in Health Care Act", which would prevent the state from imposing a Massachusetts-style individual insurance mandate on its residents.

As Sue Blevins, RN (and president of the Institute for Health Freedom) notes:

Supporters of the ballot initiative want to ensure that no health-reform scheme will strip them of their freedom to pay privately for health care. Opponents are concerned that if the initiative passes, it could preclude mandatory socialized health insurance.

Sounds good to me! I just wish Colorado voters had the chance to support a similar measure, which would go a long ways towards protecting our individual rights in health care.

Officials at the U.S. Census Bureau recently released new health insurance figures purporting to show that the number of Americans officially classified as uninsured in 2007 was 45.7 million, down from 47 million in 2006.

Despite the decline, the new figure is being spun as proof positive that America's healthcare system is still in awful shape. Advocates of socialized medicine are repeating it ad nauseam, arguing that the main problem with the country's health system is the massive uninsured population. After all, if a whopping 15 percent of the population is uninsured, then the current system must be failing.

As Dr. Oliver Fein of Physicians for a National Health Program wrote when the figure came out, "[t]he plight of the uninsured… shows how the for-profit, private health insurance model of financing health care has outlived its usefulness."

But it’s grossly misleading to use the Census Bureau number as an indication of a crisis. A closer look at the agency’s survey methods reveals that the situation isn’t nearly as bad as the pundits and the politicians would have you believe.

To generate this figure, the Census Bureau relied entirely on a questionnaire known as the Current Population Survey (CPS). The survey is intended to garner information about, among other things, the income, age, race, living situation, and, of course, health insurance status of individuals living in the United States.

As with any survey of this size and scope, the accuracy of the data it produces has substantial margins of error. As the Census Bureau itself explains in its annual report, "health insurance coverage is likely to be underreported on the Current Population Survey."

The Census Bureau doesn't tell us that 45.7 million people are chronically uninsured for the entire year. The agency has stated elsewhere that "the CPS estimate of the number of people without health insurance more closely approximates the number of people who are uninsured at a specific point in time during the year than the number of people uninsured for the entire year."

In other words, many of the survey respondents counted as "uninsured" may have experienced only a temporary interruption in their insurance. This circumstance is quite common. When workers quit or lose their job, they are technically uninsured. But they are usually in transition between one employer-provided insurance policy and another.

Despite the media’s tendency to depict the 45.7 million uninsured as a single, homogeneous group, the demographic character of these individuals cuts across age, ethnic, and socioeconomic categories. Many are uninsured for reasons unrelated to cost and don’t need to be “rescued” by mandatory socialized medicine.

We may be accustomed to thinking of the uninsured as low-income individuals and struggling families. But the Census Bureau data show that many are relatively affluent. Over 17.5 million -- 38 percent -- of the uninsured make more than $50,000 a year. And 9.1 million have an annual income of over $75,000 a year.

How can this be? In part, it's because a number of financially comfortable young Americans choose not to purchase health insurance. Known in the healthcare trade as the "invincibles" -- because they’re so sure they won't get sick -- these young singles would rather keep their money than shell out for expensive monthly insurance premiums because of the many mandates and regulations place on insurers by the states.

This intentional avoidance of health insurance is quite common. According to the Commonwealth Fund, Americans age 19-29 comprise one of the largest and fastest-growing segments of the uninsured population.

If the fact that over a third of the uninsured are pulling down more than $50,000 a year isn’t shocking enough, how about this: Nearly 10 million uninsured aren't even U.S. citizens!

It's certainly unfortunate that these individuals don't have health insurance, of course. But they can still get free treatment in emergency rooms. And even a fully nationalized healthcare system would be unlikely to provide them with health insurance.

Another 14 million of the uninsured are fully eligible for government assistance through programs like Medicare, Medicaid, and SCHIP.

How does that break down? A 2008 study by the Georgetown University Health Policy Institute showed that a whopping 70 percent of uninsured children are eligible for Medicaid, SCHIP, or both programs. And roughly 27 percent of non-elderly Americans who are eligible for Medicaid haven’t enrolled and simply live their lives without health insurance, according to the Urban Institute.

Is it really fair to say that such individuals don’t have health insurance? Further, if millions of Americans aren't availing themselves of taxpayer-funded coverage, why should we think that an even bigger government healthcare bureaucracy would solve the problem?

Of course, there are people who really do fall through the cracks. These are the chronically uninsured -- the working poor. They are people who struggle to hold down jobs and support their families. They earn less than $50,000 per year but too much to qualify for government help. They simply can’t afford insurance.

There are roughly 8 million of these chronically uninsured. Any attempt to solve the problem of the uninsured should focus on this narrow slice of the 45.7 million person pie.

The key to helping these people isn’t to create more government red tape. In fact, too much regulation is why health insurance is so expensive in the first place. What these people need is straightforward, affordable coverage that will cover them in the event of a health catastrophe. They should be able to purchase insurance in the state that has the best plan for them, regardless of where they live.

It's true that far too many Americans go without health insurance. And that is a serious problem. But the Census Bureau figure shouldn’t be presented as anything other than what it really is: an imprecise snapshot of a heterogeneous group of Americans, many of whom wouldn't benefit from additional government intrusion into the healthcare market.

It's almost as if some people want to inflate the size of the problem for their own political purposes...

Thursday, October 2, 2008

I'd like to thank the Rocky Mountain News for opposing Amendment 56, which would force most businesses to offer health insurance to their workers ("Let's make a deal/There's still time to pull some ballot measures," Sept. 3).

Businessmen create jobs through hard work and rational thought.

Consequently, they have the moral right to decide on what terms to offer these jobs to prospective employees, including specific wages and benefits.

Conversely, workers have the right to negotiate for any wages and benefits they desire, and the right to reject offers they don't like. But they have no right to demand a specific salary or benefit (such as health insurance) through government force.

To "solve" the problem of high insurance costs by foisting those costs onto businesses would be just as wrong as "solving" the problem of high gasoline prices by forcing businesses to pay their workers' gasoline expenses. The proper solution is not more government regulations but free-market reforms that address the actual underlying problems.

Gov. Deval Patrick announced in Boston that the state and the federal Centers for Medicare and Medicaid Services had negotiated the extension of a waiver that enables federal financial support for the state's subsidized coverage plan. The agreement will allow the state to spend up to $21.2 billion on the program over the next three years, an increase of $4.3 billion over the initial three-year period.

This is the plan that is so expensive that middle-class residents (e.g., a family of four making $63,000 per year) needs subsidies from the state to afford the state-mandated insurance.

The October 1, 2008 Boston Globe also reports a similar story, although it gives somewhat different figures:

...Massachusetts will be able to expand its first-in-the-nation healthcare law because of a federal promise of $10.6 billion over the next three years, Governor Deval Patrick said

The state is also adding more mandates onto businesses:

Under the new rules, the larger companies would have to pay 33 percent of their workers' premiums within 90 days of hiring and make sure that at least 25 percent of their workers are covered by the plan. Otherwise, the employer must pay a $295 fine per worker.

Businesses with fewer employees would still be allowed to follow the old rules, Bigby said, and meet only one of the two requirements to escape the penalty.

This is sure to drive even more businesses out of state.

Supporters of the Massachusetts plan like to claim that it has reduced the number of uninsured in the state. But it's cost hundreds of millions of dollars more than promised, and many of the newly insured don't actually get the care they need -- they have "coverage" but not care.

The NYT article also notes that Massachusetts officials admit that the plan might fail without the new deal made with the federal government.

If the federal government adopted a similar plan, who would bail out the US?

* HSAs have application across income groups, consumer life stages and varied employer environments.

* To encourage participation and make plans as useful as possible, employers should consider making contributions to the accounts. Even in their early years, HSAs show evidence of flexing to the specific needs of savers versus spenders.

* Positive balances at year-end are an encouraging indicator of HSAs ability to help make health care more affordable.

As one would expect, giving patient control over their medical spending decisions works!

About FIRM

America was founded on the principles of freedom and individual rights. Applied to medicine, the law must respect the individual rights of doctors and other providers, allowing them the freedom to practice medicine. This includes the right to choose their patients, to determine the best treatment for their patients, and to bill their patients accordingly. In the same manner, the law must respect the individual rights of patients, allowing them the freedom to seek out the best doctors and treatment they can afford.

Freedom and Individual Rights in Medicine (FIRM) promotes the philosophy of individual rights, personal responsibility, and free market economics in health care. FIRM holds that the only moral and practical way to obtain medical care is that of individuals choosing and paying for their own medical care in a capitalist free market. Federal and state regulations and entitlements, we maintain, are the two most important factors in driving up medical costs. They have created the crisis we face today.

Freedom and Individual Rights in Medicine was founded by Lin Zinser and Paul Hsieh, MD in 2007. It is now managed by Paul Hsieh, MD.